32  |  The Millennium Development Goals Report 2015

Target 4.A

Goal 4 Reduce by two thirds, between 1990 and 2015,

the under-five mortality rate

Reduce child Substantial progress in reducing child mortality

has been made, but more children can be saved
mortality from death due to preventable causes

Under-five mortality rate, 1990 and 2015

(deaths per 1,000 live births)
Sub-Saharan Africa
179
52%
86
Oceania
74
31%
51

Southern Asia
126
60%
50
Caucasus and Central Asia
73
55%
33
South-Eastern Asia
Key facts 71
62%
27
XX The global under-five mortality Northern Africa
rate has declined by more than 73
67%
half, dropping from 90 to 43 24
deaths per 1,000 live births Western Asia
between 1990 and 2015. 65
65%
23
XX The rate of reduction in under-
Latin America and the Caribbean
five mortality has more than 54
69%
tripled globally since the early 17
1990s.
Eastern Asia
53
XX Measles vaccination helped 78%
11
prevent nearly 15.6 million deaths
Developed regions
between 2000 and 2013.
15
61%
6
XX About 84 per cent of children
worldwide received at least one Developing regions
100
dose of measles-containing 53%
47
vaccine in 2013.
World
90
XX Every day in 2015, 16,000 53%
43
children under five continue to
die, mostly from preventable
0 50 100 150 200
causes. Child survival must
remain the focus of the post-2015 1990 2015 projection 2015 target
development agenda. Percentage change between 1990 and 2015

Note: Percentage change calculations are based on unrounded numbers.

 Goal 4: Reduce child mortality  | 33

The dramatic decline in preventable child deaths over the Focusing on newborns is critical to further
past quarter of a century is one of the most significant accelerating progress in child survival
achievements in human history. According to preliminary
estimates, the global under-five mortality rate has
declined by more than half, dropping from 90 to 43 Number of deaths by day in the first 28 days of life,
deaths per 1,000 live births between 1990 and 2015. 2013 (thousands)
This translates into almost 6 million deaths of children 1,000
under five in 2015, a decline from 12.7 million in 1990.
The under-five mortality rate has fallen by 50 per cent or
800
more in every region except Oceania.

Despite the impressive improvements in most regions, 600

current trends are not sufficient to meet the MDG target.
At today’s rate of progress, it will take about 10 more
400
years to reach the global target. The global advance in
child survival continues to elude many of the world’s
youngest children and children in the most vulnerable 200
situations. About 16,000 children under five continue
to die every day in 2015. Most of them will perish from
0
preventable causes, such as pneumonia, diarrhoea and

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Though sub-Saharan Africa has the world’s highest child
mortality rate, the absolute decline in child mortality
has been the largest over the past two decades. The
under-five mortality rate has fallen from 179 deaths per
1,000 live births in 1990 to 86 in 2015. Yet the region still
faces an urgent need to accelerate progress. Not only
does sub-Saharan Africa carry about half of the burden
of the world’s under-five deaths—3 million in 2015—but
it is also the only region where both the number of live
births and the under-five population are expected to rise
substantially over the next decades. This means that the
number of under-five deaths will increase unless progress
in reducing the under-five mortality rate is enough to
outpace population growth.
Southern Asia also continues to have both a high rate of
under-five mortality, at 50 deaths per 1,000 live births in
2015, and a large number of total deaths, at 1.8 million.
1 million deaths on the first day of life = 36% of neonatal deaths
2 million deaths in the first week = 73% of neonatal deaths
The first day, week and month of life are the most critical
for the survival of children. Of the almost 6 million
children who die before their fifth birthday in 2015, about
1 million will take their first and final breath on the day
they are born. An additional 1 million will die in the first
week, and around 2.8 million will die during their first
28 days of life (the neonatal period).
Between 1990 and 2015, the worldwide neonatal
mortality rate has fallen from 33 deaths to 19 deaths per
1,000 live births. As the decline in neonatal mortality
has been slower than the decline in mortality for children
aged 1–59 months, neonatal deaths now represent a
larger share of total under-five deaths. Every region of
the world is experiencing an increase in the proportion of
under-five deaths that occur in the neonatal period.

The majority of neonatal deaths worldwide are caused by

preterm birth complications (35 per cent), complications
during labour and delivery (24 per cent) and sepsis (15
per cent). In sub-Saharan Africa and Southern Asia
many deaths are also due to preventable infectious
diseases. Many neonatal deaths could be avoided with
simple, cost-effective and high-impact interventions
that address the needs of women and newborns across
the continuum of care, with an emphasis on care around
the time of birth. However, analysis shows that too
many newborns and mothers miss out on these key
interventions.
34  |  The Millennium Development Goals Report 2015
Further improvements in child survival
require concerted efforts to reduce
socioeconomic disparities
Ratio of under-five mortality rate for children by residence,
wealth quintile and mother’s education, 2005¬2013
Rural to urban
1.7
Poorest to richest households
1.9
Children born to mothers with no education
to children born to mothers with primary education
1.5
Children born to mothers with no education
to children born to mothers with secondary or higher education
2.8
0.0 1.0 2.0 3.0
Note: Data are based on the MICS and DHS survey that took place
between 2005 and July 2013. Data from most recent survey in that period
are used for countries with multiple surveys. Data by wealth quintile are
based on 55 surveys, data on education are based on 59 surveys, data on
residence are based on 60 surveys.
The dramatic improvement in child survival is welcome
news, but not every family is sharing equally in this
success. Household survey data suggest that children
from poorer households remain disproportionately
vulnerable compared with the wealthiest households.
On average, under-five mortality rates are almost twice
as high for children in the poorest households as for
children in the richest.
Mortality is also more likely to strike children in rural
areas. These children are about 1.7 times more likely
to die before their fifth birthday as those in urban
areas. Mother’s education remains the most powerful
determinant of inequality in survival. Children of mothers
with secondary or higher education are almost three
times as likely to survive as children of mothers with no
education.
Under-five mortality has been declining faster among the
poorest households in the most recent decade, a sign of
improving equity. As the pace of progress accelerates
among these households, the gap between the richest
and poorest households is narrowing in most regions.
The disparities in under-five mortality by mother’s
education and residence are also narrowing in some
countries. Sustaining this progress calls for strategies
that target the most vulnerable children from the poorest
households and from rural areas, and that support
women’s education and empowerment. Also needed are
continued efforts to monitor and report the inequities
that are often concealed by global or national averages.
 Goal 4: Reduce child mortality  | 35

Child mortality rates are falling Under-five mortality is declining faster than at any other
faster than ever time during the past two decades. The global annual
rate of reduction has more than tripled since the early
Annual rate of reduction in the under-five mortality rate 1990s. In sub-Saharan Africa, despite the relatively high
in developing regions, 1990¬2013 (percentage) rate of under-five mortality, the rate of decline was over
five times faster during 2005–2013 than it was during
Oceania 1990–1995, accelerating from 0.8 per cent per year to
1.4 4.2 per cent per year.
0.7
1.0
2.1 The annual rate of reduction in under-five mortality has
South-Eastern Asia accelerated since 1995 in countries of all income levels
4.0 except in high-income countries. Although there is a
3.8 link between a country’s level of income and its child
4.3
3.7
mortality, the strong reductions in under-five mortality
rates in a number of low-income countries—notably,
Latin America and the Caribbean
Bangladesh, Cambodia, Eritrea, Ethiopia, Liberia,
4.7
5.6 Madagascar, Malawi, Mozambique, Nepal, Niger,
5.1 Rwanda, Uganda and United Republic of Tanzania—
4.1
prove that low income need not be an impediment to
Southern Asia saving children’s lives.
2.9
3.4
3.9
4.1

Northern Africa
4.8
5.0
4.9
4.1

Sub-Saharan Africa
0.8
1.9
3.8
4.2

Caucasus and Central Asia

-0.4
3.0
5.0
4.3

Western Asia
4.0
4.5
4.1
4.4

Eastern Asia
2.7
4.7
8.7
7.7

-1 0 1 2 3 4 5 6 7 8 9 10

1990¬1995 1995¬2000 2000¬2005 2005¬2013

36  |  The Millennium Development Goals Report 2015

Measles immunization has saved millions Measles deaths have declined rapidly since 2000, from
of children’s lives, but progress towards 544,200 deaths to 145,700 deaths in 2013, mostly
among children under five years of age. Compared
eliminating measles has stalled with estimated mortality in the absence of a measles
vaccination programme, nearly 15.6 million deaths were
Estimated child deaths due to measles (thousands) and averted by measles vaccination between 2000 and 2013.
proportion of children in the appropriate age group who Measles deaths in sub-Saharan Africa (96,000) and
received at least one dose of measles-containing vaccine Southern Asia (39,800) accounted for 93 per cent of the
(percentage), 1990¬2013 estimated measles deaths worldwide during 2013.
Thousands Percentage
700 100 Also, between 2000 and 2013, the number of annual
reported measles cases globally declined by 67 per cent,
from more than 853,000 in 2000 to under 279,000 in
600 95
2013. However, the number of measles cases in 2013
increased from the 2012 level of 227,700. Unfortunately,
500 90 continued outbreaks—due to weak routine immunization
systems and delayed implementation of accelerated
400 85
disease control—have stalled momentum towards
achievement of regional and global targets for measles
control and elimination.
300 80
Measles can be prevented with two doses of a safe,
200 75 effective and inexpensive vaccine. Between 2000 and
2009, global coverage with the first dose of measles-
containing vaccine (MCV1) increased from 73 per cent
100 70
to 83 per cent, but it stagnated at 83–84 per cent from
2010 to 2013. The most impressive progress was made
0 65 in sub-Saharan Africa, where coverage increased from
1990 1995 2000 2005 2010 2013 53 per cent in 2000 to 74 per cent in 2013. Between
Left axis: Child deaths in sub-Saharan Africa 2000 and 2013, the number of countries providing a
second dose of the vaccine (MCV2) increased from
Child deaths in Southern Asia
96 to 148, and global coverage of MCV2 increased from
Child deaths in other regions
15 to 53 per cent.
Right axis: Global proportion of children who received vaccine
Impressive as these gains are, progress has stalled
since 2010 and remains fragile. An estimated 21.6
million infants did not receive MCV1 in 2013. Many
of them are from the poorest and most marginalized
communities, residing in especially hard-to-reach areas.
Ramping up progress will require countries and the
international community to continue to campaign for
measles elimination. Achieving equitable increases in
immunization coverage will also require substantial and
sustained investments in strengthening health systems.

Child survival must remain at the heart of the post-2015 global development agenda
Reducing under-five mortality requires political will,
sound strategies and adequate resources. The MDGs
have led to dramatic and unprecedented progress
in reducing child deaths. Effective and affordable
treatments, improved service delivery and political
commitment have all contributed. Yet every minute
around the world, 11 children die before celebrating their
fifth birthday, mostly from preventable causes. More
work is needed to improve child survival rates.
Goal 4: Reduce child mortality  | 37
Achievement of Goal 4 by a significant number of
countries, even very poor countries, shows that it can be
done. With millions of women and children still at risk
of dying of preventable causes, maternal, newborn and
child survival must remain at the heart of the post-2015
global development agenda.